Get in the Game USA!

MSF Cruise for a Cause
     Get in the Game USA
              Division of Palm Beach County Cruise and Travel, Inc.,
  Ft. Lauderdale , FL, 33301

877-222-0835, info@getinthegameusa.com

         The Client Booking Form* located below, is to be filled out and submitted to book
         our cruise.   If payment of deposit is by credit card, please indicate and call us at
         877- 222-0835 with your information. If payment is by check, please indicate
         and mail payment within 4 days of completion of this form to PBCCT at 333 Las
         Olas Way, Suite 1407, Fort Lauderdale, Florida 33301.

* Required Fields

Title:	Last Name: *	First Name: *	M.I.


Email Address: *	Phone (Home) *	Phone (Cell)	Phone (Work)

Address: *

Apt #:

City: *

State: *

Zip: *

Check this box if you
have a secondary address

Date From:

Date To:

Address:	Apt #:	City:	State:	Zip:

Family Members (Include Primary Person and Spouse)
Name:	Address, City, State, Zip:	D.O.B.:	Age	Passport #/Exp:

Cruise Details

Cruise Line:

Name of Ship:

Depart Date:

End Date:

Freedom of the Seas

4/29/2012

5/6/2012

Group #'s:

Category:

Number of Passengers:

# of Cabins needed:

MSF 3670662

Bed Arrangements:

Cruise $ PP passengers, 1 & 2:

additional passengers $:

Tx, prt, chrgs, grats, &
doc. fees pp:

Twin Queen

$395.07

Dining Preference:

Group Early (6:00PM) My Time Late (8:15PM)

Cabin Total:

Insurance total:

Grand Total:

Total Deposit Amt:

(call for pricing)

Cruise deposit by
Credit Card:

Use same Credit Card as on MSF 2011 Cruise

Name on Card

*Cruise Deposit
by check.

Last 4 Digits of Card:

Expiration:

Motorized Scooter Rental:

If scooter rental is needed please enter your
height & weight below:

Yes No

Height: Weight:

Payment Plan:

Interested in a Payment Plan? Yes No

Send Final Documents to:

Occasion/Celebration:

Special Needs/Other:

Refrigerator? Yes No
Sharps Container: Yes No
Shower Stool: Yes No
Raised Toilet Seat: Yes No
Bringing a Service Dog: Yes No
Other Request:

Confined to a wheelchair/scooter? Yes No
Accessible handicap room required? Yes No
(Please be considerate of those in need.)

Will you be bringing your own scooter? Yes No
If Yes, how many?

Single supplement? Yes No

Wish to be paired with a roommate? Yes No

Age:
Smoker: Yes No

Phone number where roommate can reach you:

Future cruise credit or other promo:

Crown and Anchor number:
Passenger A B

Comments:

Travel Verification (Signature Required):

I, ,have reviewed the dates, times, and reservations made on my behalf by Palm Beach County Cruise and Travel. I agree that they are correct and accurate. I understand that Palm Beach County Cruise and Travel is not responsible for any cancellation, error or omissions on my behalf of or the behalf of vendors providing travel services as a result of this reservation. I also understand that tips, taxes and charges on unescorted meals and tours are my responsibility unless other wise stated.

Cruise: I understand the cancellation/amendment policies of the vendor’s travel program that I have purchased. In addition, I understand that Palm Beach County Cruise and Travel may assess a 15% of base cruise price per person fee as a result of any changes/cancellation of this transaction and a $52.00 p.p. administrative fee. I agree to pay all charges fees, and/or penalties, and hereby hold Palm Beach County Cruise and Travel free of any claims made as a result of the changes/cancellation of this travel reservation.

Insurance: No refunds of insurance will be given 7 days after policy is issued.

*Taxes and fees subject to change without notification.

Date: Client Signature:

Anti-Spam -What is 8 plus 4?: Wrong.Wrong.Wrong.Wrong.Wrong.Wrong.

Get in the Game USA
333 Las Olas Way, Suite 1407 Ft. Lauderdale, FL 33301
877-222-0835, info@getinthegameusa.com